High-resolution CT with arch/neck/head CT angiography on a mobile stroke unit

2021 ◽  
pp. neurintsurg-2021-017697
Author(s):  
Anne W Alexandrov ◽  
Adam S Arthur ◽  
Tomas Bryndziar ◽  
Victoria M Swatzell ◽  
Wendy Dusenbury ◽  
...  
Keyword(s):  
High Resolution ◽  
Hemorrhagic Stroke ◽  
Diagnostic Yield ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Time Averaging ◽  
Vessel Occlusion ◽  
Spot Sign ◽  
Mobile Stroke Unit ◽  
Hospital Transfer ◽  
Contrast Ct

BackgroundMobile stroke units (MSUs) performance dependability and diagnostic yield of 16-slice, ultra-fast CT with auto-injection angiography (CTA) of the aortic arch/neck/circle of Willis has not been previously reported.MethodsWe performed a prospective observational study of the first-of-its kind MSU equipped with high resolution, 16-slice CT with multiphasic CTA. Field CT/CTA was performed on all suspected stroke patients regardless of symptom severity or resolution. Performance dependability, efficiency and diagnostic yield over 365 days was quantified.Results1031 MSU emergency activations occurred; of these, 629 (61%) were disregarded with unrelated diagnoses, and 402 patients transported: 245 (61%) ischemic or hemorrhagic stroke, 17 (4%) transient ischemic attack, 140 (35%) other neurologic emergencies. Total time from non-contrast CT/CTA start to images ready for viewing was 4.0 (IQR 3.5–4.5) min. Hemorrhagic stroke totaled 24 (10%): aneurysmal subarachnoid hemorrhage 3, hemorrhagic infarct 1, and 20 intraparenchymal hemorrhages (median intracerebral hemorrhage score was 2 (IQR 1–3), 4 (20%) spot sign positive). In 221 patients with ischemic stroke, 73 (33%) received alteplase with 31.5% treated within 60 min of onset. CTA revealed large vessel occlusion in 66 patients (30%) of which 9 (14%) were extracranial; 27 (41%) underwent thrombectomy with onset to puncture time averaging 141±90 min (median 112 (IQR 90–139) min) with full emergency department (ED) bypass. No imaging needed to be repeated for image quality; all patients were triaged correctly with no inter-hospital transfer required.ConclusionsMSU use of advanced imaging including multiphasic head/neck CTA is feasible, offers high LVO yield and enables full ED bypass.

Prehospital Computed Tomography Angiography in Acute Stroke Management

2017 ◽  
Vol 44 (5-6) ◽  
pp. 338-343 ◽  
Author(s):  
Michael Kettner ◽  
Stefan Alexander Helwig ◽  
Andreas Ragoschke-Schumm ◽  
Lenka Schwindling ◽  
Safwan Roumia ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Acute Stroke ◽  
Point Of Care ◽  
Vascular Pathology ◽  
Ct Scanner ◽  
Vessel Occlusion ◽  
Spot Sign ◽  
Specialized Treatment ◽  
Mobile Stroke Unit ◽  
Prehospital Management

Background: An ambulance equipped with a computed tomography (CT) scanner, a point-of-care laboratory, and telemedicine capabilities (mobile stroke unit [MSU]) has been shown to enable the delivery of thrombolysis to stroke patients directly at the emergency site, thereby significantly decreasing time to treatment. However, work-up in an MSU that includes CT angiography (CTA) may also potentially facilitate triage of patients directly to the appropriate target hospital and specialized treatment, according to their individual vascular pathology. Methods: Our institution manages a program investigating the prehospital management of patients with suspicion of acute stroke. Here, we report a range of scenarios in which prehospital CTA could be relevant in triaging patients to the appropriate target hospital and to the individually required treatment. Results: Prehospital CTA by use of an MSU allowed to detect large vessel occlusion of the middle cerebral artery in one patient with ischemic stroke and occlusion of the basilar artery in another, thereby allowing rational triage to comprehensive stroke centers for immediate intra-arterial treatment. In complementary cases, prehospital imaging not only allowed diagnosis of parenchymal hemorrhage with a spot sign indicating ongoing bleeding in one patient and of subarachnoid hemorrhage in another but also clarified the underlying vascular pathology, which was relevant for subsequent triage decisions. Conclusion: Defining the vascular pathology by CTA directly at the emergency site may be beneficial in triaging patients with various cerebrovascular diseases to the most appropriate target hospital and specialized treatment.

Bubble study as a medium of contrast for computerized tomography coronary angiography. (Preprint)

2020 ◽  
Author(s):  
Vijay Shah ◽  
Justyn Huang
Keyword(s):  
Pulmonary Artery ◽  
Diagnostic Yield ◽  
Negative Contrast ◽  
Hounsfield Unit ◽  
Hounsfield Units ◽  
Computed Tomographic ◽  
Invasive Test ◽  
Clinical Difference ◽  
Contrast Ct ◽  
Scan Protocol

BACKGROUND Computed tomographic coronary angiogram (CTCA) is a non-invasive test with a negative predictive value of nearly 100% for the detection of coronary artery study. While diagnostic yield of a dedicated CTCA with bubble contrast is not yet evaluated OBJECTIVE To assess the diagnostic performance of injected bubble contrast and ability to measure difference in hounsfield units and use it as a "negative contrast" in computed tomographic METHODS This is a single center, single patient study. Baseline acquisition of a non-contrast CT scan was acquired to get hounsfield unit count in the aorta and pulmonary artery- (Calcium scan protocol) 1.4 mGy (19.5 mGy/cm). Secondly, Echo contrasts (Definity) - 5mls was injected and an echocardiogram confirmed filling in the aortic region. Finally, bubble contrast (1ml air, 8mls water and 1mls blood was drawn up and agitated through a 3 way tap) - was injected, a timing run was initiated to calculate for the bubbles to opacity the pulmonary artery. The same scan protocol was used– 1.4 mGy (19.5 mGy/cm). RESULTS Hounsfield units’ difference in the aorta and pulmonary artery from baseline compared to echo contrast and bubble contrast were not significant. CONCLUSIONS We believe this is the first ever recorded case to use bubbles as CT contrast. While results were not significant, secondary to small volume of bubbles injected. Further research needs to be implemented to assess clinical difference with amount of bubbles and volume required. CLINICALTRIAL Single centre study

scholarly journals Impact of mobile stroke units

2021 ◽  
pp. jnnp-2020-324005
Author(s):  
Klaus Fassbender ◽  
Fatma Merzou ◽  
Martin Lesmeister ◽  
Silke Walter ◽  
Iris Quasar Grunwald ◽  
...  
Keyword(s):  
Cost Efficiency ◽  
Current Knowledge ◽  
Vascular Imaging ◽  
Vessel Occlusion ◽  
Stroke Units ◽  
Stroke Treatment ◽  
Stroke Research ◽  
Mobile Stroke Unit ◽  
Novel Strategy

Since its first introduction in clinical practice in 2008, the concept of mobile stroke unit enabling prehospital stroke treatment has rapidly expanded worldwide. This review summarises current knowledge in this young field of stroke research, discussing topics such as benefits in reduction of delay before treatment, vascular imaging-based triage of patients with large-vessel occlusion in the field, differential blood pressure management or prehospital antagonisation of anticoagulants. However, before mobile stroke units can become routine, several questions remain to be answered. Current research, therefore, focuses on safety, long-term medical benefit, best setting and cost-efficiency as crucial determinants for the sustainability of this novel strategy of acute stroke management.

scholarly journals Rupture Risk of Intracranial Aneurysm and Prediction of Hemorrhagic Stroke after Liver Transplant

2021 ◽  
Vol 11 (4) ◽  
pp. 445
Author(s):  
Hye-Mee Kwon ◽  
In-Gu Jun ◽  
Kyoung-Sun Kim ◽  
Young-Jin Moon ◽  
In Young Huh ◽  
...  
Keyword(s):  
Risk Factors ◽  
Intracranial Aneurysm ◽  
Hemorrhagic Stroke ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Hazard Analysis ◽  
Related Data ◽  
Incidence And Mortality ◽  
Before And After ◽  
History Of ◽  
Cirrhotic Patients

Postoperative hemorrhagic stroke (HS) is a rare yet devastating complication after liver transplantation (LT). Unruptured intracranial aneurysm (UIA) may contribute to HS; however, related data are limited. We investigated UIA prevalence and aneurysmal subarachnoid hemorrhage (SAH) and HS incidence post-LT. We identified risk factors for 1-year HS and constructed a prediction model. This study included 3544 patients who underwent LT from January 2008 to February 2019. Primary outcomes were incidence of SAH, HS, and mortality within 1-year post-LT. Propensity score matching (PSM) analysis and Cox proportional hazard analysis were performed. The prevalence of UIAs was 4.63% (n = 164; 95% confidence interval (CI), 3.95–5.39%). The 1-year SAH incidence was 0.68% (95% CI, 0.02–3.79%) in patients with UIA. SAH and HS incidence and mortality were not different between those with and without UIA before and after PSM. Cirrhosis severity, thrombocytopenia, inflammation, and history of SAH were identified as risk factors for 1-year HS. UIA presence was not a risk factor for SAH, HS, or mortality in cirrhotic patients post-LT. Given the fatal impact of HS, a simple scoring system was constructed to predict 1-year HS risk. These results enable clinical risk stratification of LT recipients with UIA and help assess perioperative HS risk before LT.

scholarly journals Solid Swallow Examination During High Resolution Manometry and EGJ-Distensibility Help Identify Esophageal Outflow Obstruction in Non-obstructive Dysphagia

Dysphagia ◽  
2021 ◽  
Author(s):  
Fritz Ruprecht Murray ◽  
Lara Maria Fischbach ◽  
Valeria Schindler ◽  
Larissa Schnurre ◽  
Juliane Marie Hente ◽  
...  
Keyword(s):  
High Resolution ◽  
Diagnostic Yield ◽  
Diagnostic Value ◽  
Control Group ◽  
Clinical Response Rate ◽  
Interventional Treatment ◽  
Outflow Obstruction ◽  
Motility Disorders ◽  
High Resolution Manometry ◽  
Solid Swallows

AbstractSingle water swallow (SWS) high-resolution manometry (HRM) may miss relevant esophageal motility disorders. Solid test meal (STM) during HRM and lately the functional lumen imaging probe (FLIP) have been shown to be of diagnostic value in the assessment of motility disorders. We aimed to assess the diagnostic yield of STM and FLIP in non-obstructive dysphagia (NOD). Patients assessed for dysphagia with both HRM and FLIP between April 2016 and August 2019 were analyzed for signs of non-obstructive EGJ outflow obstruction (EGJOO) according to Chicago Classification 3.0 (CCv3) and CC adapted for the use with solid swallows (CC-S), followed by an individual group-specific analysis. Five subjects without dysphagia served as control group. Standard HRM- and FLIP-values as well as esophagograms and Eckardt Scores were analyzed. Forty-two patients were identified (male/female, 14/36, median age 62). Twenty-five (59.5%) were diagnosed with EGJOO during STM only (= SWS-negative patients; CC-S). The EGJ distensibility index (EGJ-DI) of symptomatic patients was significantly lower compared to the control group (p = 0.006). EGJ-DI was < 3mm2/mmHg in 67% and 88% of patients diagnosed according to CC-S and CCv3, respectively. The IRP during STM showed a significant association to the corresponding EGJ-DI values (p < 0.001). Seventy-six percent of patients received treatment because of additional STM evaluation with a favorable clinical response rate of 89%. STM and FLIP identify EGJOO in symptomatic patients with normal SWS during HRM. STM resembles an inexpensive and clinically meaningful option to diagnose motility disorders and helps to select patients for interventional treatment.

Abstract T P243: Mortality Among Transferred Hemorrhagic Stroke Patients in United States: An Analysis From National Database

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Malik M Adil ◽  
Shyam Prabhakaran
Keyword(s):  
Hospital Mortality ◽  
Hemorrhagic Stroke ◽  
Inpatient Rehabilitation ◽  
National Database ◽  
Stroke Patients ◽  
Discharge Outcomes ◽  
Hospital Transfer ◽  
Transferred Patients ◽  
Surgical Treatments ◽  
Acute Rehabilitation

Background: Hemorrhagic stroke patients may require inter-facility transfer for higher level of care. Limited data are available on outcome of transferred patients. Objective: To determine in-hospital mortality and discharge outcomes among transferred hemorrhagic stroke patients. Methods: Data from all patients admitted to US hospitals between 2008 and 2011 with a primary discharge diagnosis of hemorrhagic stroke [intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH)] were identified by ICD-9 codes (ICH: 431; SAH: 430). In separate models for ICH and SAH using logistic regression, the odds ratio (OR) and 95% confidence intervals (CI) for in-hospital mortality and good outcome (discharge home or inpatient rehabilitation) among transfer vs. non-transfers were estimated, after adjusting for potential confounders. Results: Of 290,395 patients with ICH, 48,749 (16.8%) arrived by inter-hospital transfer; for SAH, 25,726 (33%) of 78,156 were transfers. In-hospital mortality was lower among ICH transfers (21.2% vs. 23.2%; p=0.004). In adjusted analyses, in-hospital mortality was not significantly different (p=0.20) while discharge to home or inpatient rehabilitation was more likely among transferred ICH patients (OR 1.1, 95% CI 1.0-1.2, p=0.05). In-hospital mortality was lower for SAH transfers (17.4% vs. 22.9%, p<0.001) and remained significant in adjusted analyses (OR 0.7, 95% CI 0.6-0.8). Transferred SAH patients were also more likely to be discharged to home or inpatient rehabilitation (OR 1.2, 95% CI 1.1-1.4, p<0.001). Coiling and clipping procedures were significantly more common in SAH transferred patients while cerebral angiography, mechanical ventilation and gastrostomy were significantly higher in both ICH and SAH transfer patients. Conclusion: While ICH patients arriving by transfer have similar mortality as non-transfers, they are more likely to be discharged to home or acute rehabilitation. For SAH, transfer confers both mortality and outcome benefit. Definitive surgical treatments and aggressive medical supportive care at receiving hospitals may mediate the benefits of inter-hospital transfer in hemorrhagic stroke patients.

Prognostic importance of CT ASPECTS and CT perfusion measures of infarction in anterior emergent large vessel occlusions

2018 ◽  
Vol 11 (7) ◽  
pp. 670-674 ◽  
Author(s):  
Syed Ali Raza ◽  
Clara M Barreira ◽  
Gabriel M Rodrigues ◽  
Michael R Frankel ◽  
Diogo C Haussen ◽  
...  
Keyword(s):  
Ct Perfusion ◽  
Area Under The Curve ◽  
Large Vessel ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Median Baseline ◽  
Ct Head ◽  
Prognostic Importance ◽  
Contrast Ct

BackgroundAge, neurologic deficits, core volume (CV), and clinical core or radiographic mismatch are considered in selection for endovascular therapy (ET) in anterior circulation emergent large vessel occlusion (aELVO). Semiquantitative CV estimation by Alberta Stroke Programme Early CT Score (CT ASPECTS) and quantitative CV estimation by CT perfusion (CTP) are both used in selection paradigms.ObjectiveTo compare the prognostic value of CTP CV with CT ASPECTS in aELVO.MethodsPatients in an institutional endovascular registry who had aELVO, pre-ET National Institutes of Health Stroke Scale (NIHSS) score, non-contrast CT head and CTP imaging, and prospectively collected 3-month modified Rankin Scale (mRS) score were included. Age- and NIHSS-adjusted models, including either CT ASPECTS or CTP volumes (relative cerebral blood flow <30% of normal tissue, total hypoperfusion, and radiographic mismatch), were compared using receiver operator characteristic analyses.ResultsWe included 508 patients with aELVO (60.8% M1 middle cerebral artery, 34% internal carotid artery, mean age 64.1±15.3 years, median baseline NIHSS score 16 (12–20), median baseline CT ASPECTS 8 (7–9), mean CV 16.7±24.8 mL). Age, pre-ET NIHSS, CT ASPECTS, CV, hypoperfusion, and perfusion imaging mismatch volumes were predictors of good outcome (mRS score 0–2). There were no differences in prognostic accuracies between reference (age, baseline NIHSS, CT ASPECTS; area under the curve (AUC)=0.76) and additional models incorporating combinations of age, NIHSS, and CTP metrics including CV, total hypoperfusion or mismatch volume (AUCs 0.72–0.75). Predicted outcomes from CT ASPECTS or CTP CV-based models had excellent agreement (R2=0.84, p<0.001).ConclusionsIncorporating CTP measures of core or penumbral volume, instead of CT ASPECTS, did not improve prognostication of 3-month outcomes, suggesting prognostic equivalence of CT ASPECTS and CTP CV.

scholarly journals Transocular sonography in acute arterial occlusions of the eye in elderly patients: Diagnostic value of the spot sign

PLoS ONE ◽  
2021 ◽  
Vol 16 (2) ◽  
pp. e0247072
Author(s):  
Michael Czihal ◽  
Christian Lottspeich ◽  
Anton Köhler ◽  
Ilaria Prearo ◽  
Ulrich Hoffmann ◽  
...  
Keyword(s):  
Elderly Patients ◽  
Interobserver Agreement ◽  
Diagnostic Yield ◽  
Central Retinal Artery Occlusion ◽  
Retinal Artery Occlusion ◽  
Diagnostic Value ◽  
Artery Occlusion ◽  
Ischemic Optic Neuropathy ◽  
Spot Sign ◽  
Retinal Artery

Purpose To characterize the diagnostic yield of the spot sign in the diagnostic workup of acute arterial occlusions of the eye in elderly patients. Methods Clinical characteristics of consecutive patients aged ≥ 50 years with acute central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO) or anterior ischemic optic neuropathy (AION) were recorded. Videos of transocular sonography were assessed for the presence of the spot sign by two blinded readers. Group comparisons were made between CRAO-patients with and without the spot sign. Two experienced cardiovascular physicians allocated CRAO-cases to a presumed aetiology, without and with knowledge on the presence/absence of the spot sign. Results One-hundred-twenty-three patients were included, 46 of whom suffered from CRAO. A spot sign was seen in 32 of 46 of patients with CRAO and in 7 of 23 patients with BRAO. Interobserver agreement was excellent (Cohen`s kappa 0.98). CRAO-patients with the spot sign significantly more frequently had a medical history of cardiovascular disease (62.8 vs. 21.4%, p = 0.03) and left heart valve pathologies (51.9 vs. 10%, p = 0.03). The spot sign was not found in any of the three patients with CRAO secondary to cranial giant cell arteritis. The assumed CRAO aetiology differed in 37% of cases between two cardiovascular physicians, regardless whether transocular sonography findings were known or not. Conclusion The spot sign is a simple sonographic finding with excellent interobserver agreement, which proofs the embolic nature of CRAO, but does not allow exact attribution of the underlying aetiology.

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